Focusing Well-Women

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PRECONCEPTION CARE WHAT IT IS and WHAT IT ISNT
The National Preconception Curriculum Resources
Guide for Clinicians MODULE 1 Release Date May
2008 Termination Date June 2009 Sponsored by
Albert Einstein College of Medicine and
Montefiore Medical Center in joint sponsorship
with the University of North Carolina Center for
Maternal Infant Health.
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• Faculty
• Merry-K Moos, BSN, FNP, MPH, FAAN Professor of
  Obstetrics Gynecology, UNC School of Medicine,
  Chapel Hill, NC
• Peter Bernstein, MD, MPH, Associate Professor
  of Obstetrics Gynecology, Albert Einstein
  College of Medicine, Bronx, NY
• Disclosures
• Dr. Bernstein and Ms. Moos present no conflict
  of interest. They will not present any off-label
  or investigational uses of drugs/devices in this
  activity.

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Accreditation StatementThis activity has been
planned and implemented in accordance with the
Essential Areas and Policies of the Accreditation
Council for Continuing Medical Education (ACCME)
through joint sponsorship of Albert
EinsteinCollege of Medicine and the University
of North Carolina Center for Maternal Infant
Health.  Albert Einstein College of Medicine is
accredited by the ACCME to provide continuing
medical education for physicians. Credit
Designation Statement Albert Einstein College of
Medicine designates this educational activity for
a maximum of 1AMA PRA Category 1 Credit.
Physicians should only claim credit commensurate
with the extent of their participation in the
activity.
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Objectives

• Explain the rationale for changing the perinatal
  prevention paradigm to include an emphasis on
  preconceptional health
• Link major threats to womens health with major
  threats to pregnancy outcomes
• Identify three tiers for promoting high levels of
  preconceptional wellness in populations of
  childbearing age.
• Begin to develop strategies to view every
  encounter with a woman of childbearing age as an
  opportunity for health promotion and disease
  prevention through the life cycle.

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Outline

• The rationale for preconceptional health
  promotion
• Major milestones in the movement
• What it means for providers of womens health
  care
• Overview of curriculum components and their
  relationship to national preconception initiative

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THE RATIONALE for PRECONCEPTION HEALTH PROMOTION
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• The U.S. infant mortality rate is higher than
  many other countries (click here for
  international comparisons)
• Although higher percentages of women receive
  early prenatal care than ever before, preterm
  birth and low birth weight rates are increasing
  (click here to see preterm and low birth weight
  trends) and declines in infant mortality have
  stalled (click here to see infant mortality
  trends)

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INTERNATIONAL COMPARISONS OF INFANT MORTALITY
RATES 2004
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MODs Peristats, 2004
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Preterm birth
US, 1994-2004
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Preterm is less than 37 completed weeks
gestation. Source National Center for Health
Statistics, final natality data. Retrieved July
30, 2007, from www.marchofdimes.com/peristats.
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Preterm birth in the U.S.

• In 2004, 1 in 8 babies (12.5 of live births)
  were born preterm in the United States. Preterm
  birth affected approximately 513,875 infants that
  year.
• In 2000, The Healthy People 2010 goal for preterm
  births was set. The goal is to reduce the rate
  of preterm birth to no more than 7.6 of all live
  births by 2010.
• Movement is in the wrong direction! 

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Low birth weight
US, 1994-2004
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Low birthweight is less than 2500 grams (5 1/2
pounds). Source National Center for Health
Statistics, final natality data. Retrieved July
30, 2007, from www.marchofdimes.com/peristats.
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Low birth weight in the U.S.

• In 2004, 1 in 12 babies (8.1 ) were born
  weighing less than 2500 gms. Low birth weight
  affected approximately 332,991 infants
• In 2000, the Healthy People 2010 goal for low
  birth weight was set. The goal is to reduce the
  rate of low birth weight to 5.0 of live births
  by the end of this decade.
• Between 1994 and 2004, the rate of infants born
  low birth weight in the United States increased
  11.

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Infant mortality rates
US, 1994-2004


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Deaths to infants less than one year of age.
Source National Center for Health Statistics,
final mortality data, 199-1994 and period linked
birth/infant death data, 1995-present. Retrieved
April 22, 2008, from www.marchofdimes.com/peristat
s.
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Infant mortality rates in the U.S.

•  In 2004, the infant mortality rate was 6.8
  deaths per 1,000 live births. Approximately
  27,860 babies born that year died before their
  first birthday.
•  Between 1994 and 2004, the infant mortality rate
  in the United States declined 15.

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How Does Your State Compare?

• Peristats is an interactive program hosted by the
  March of Dimes Birth Defects Foundation to help
  clinicians and policy makers understand trends
  and comparisons regarding major maternal and
  child health indicators.
• Using Peristats can help you develop an
  appreciation of your own locale, produce handouts
  and slides and stay up to date.
• Click here to go to www.marchofdimes.com/peristats
  to learn more about the U.S. and your own state

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Incidence of Adverse Pregnancy Outcomes, 2004
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• The preconception movement is based on the
  realization that
• Prenatal care starts too late to prevent many of
  these poor pregnancy outcomes
• Women who have higher levels of health before
  pregnancy have healthier reproductive outcomes

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In obstetrics. . . many of our outcomes or
their determinants are present before we ever
meet our patients
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Important Examples

• Intendedness of conception
• Interpregnancy interval
• Maternal age
• Exposure ART/ovulation stimulation
• Spontaneous abortion
• Abnormal placentation
• Chronic disease control
• Congenital anomalies
• Timing of entry into prenatal care

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Over time, it has come to be realized that
Preconceptional Health Promotion provides a
pathway to
the Primary Prevention of many poor pregnancy
outcomes beyond that available through
traditional prenatal care
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EXAMPLES OF PRIMARY PREVENTION of Congenital
Anomalies

• Prevention of neural tube defects
• Birth Defects related to poor glycemic control of
  mother (including sacral agenesis, cardiac
  defects and neural tube defects)

• 50-70 can be prevented if a woman has adequate
  levels of folic acid during earliest weeks of
  organogenesis
• Can be reduced from 10 to 2-3 through glycemic
  control of the mother before organogenesis

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EXAMPLES OF PRIMARY PREVENTION of Congenital
Anomalies

• Maternal exposure to teratogenic exposures such
  as prescribed regimens, environmental exposures
  and alcohol

• Teratogenic substances interfere with normal
  organ development primarily during the period of
  organogenesis
• Click here for chart illustrating the
• critical window of organogenesis for
• various organ systems

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Critical Periods of Development
Critical Periods of Development
Weeks gestation

4 5 6 7 8 9
10 11 12
from LMP
Most susceptible

Central Nervous System
Central Nervous System
time for major

malformation
Heart
Heart
Arms
Arms
Eyes
Eyes
Legs
Legs
Teeth
Teeth
Palate
Palate
External genitalia
External genitalia
Ear
Ear
Mean Entry into Prenatal Care
Missed Period
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Preconception health promotion and health care
are not new concepts they have been gaining
momentum for the last three decades
Freda, Moos Curtis. MCHJ, 200610S43
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A Brief History of the Preconception Movement
Major Milestones
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The 1980s

• In 1983, the first Guidelines for Perinatal
  Care (joint publication of ACOG and AAP) noted,
  Preparation for parenthood should begin prior to
  conception. At the time of conception the couple
  should be in optimal physical health and
  emotionally prepared for parenthood.
• AAP/ACOG. Guidelines for Perinatal
  Care. 1983 (p257).

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The 1980s

• In 1985, the report of the Institute of
  Medicines Committee to Study the Prevention of
  Low Birthweight emphasized the importance of
  prepregnancy risk identification, counseling and
  risk reduction.
• (click here to read the Committees rationale
  for restructuring the perinatal prevention
  paradigm)

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IOM Committee to Study Prevention of Low
Birthweight Statement on Preconception Health

• Much of the literature about preventing low
  birthweight focuses on the period of
  pregnancyhow to improve the content of prenatal
  care, how to motivate women to reduce risky
  habits while pregnant, how to encourage women to
  seek out and remain in prenatal care. By
  contrast, little attention is given to
  opportunities for prevention before pregnancy. . .

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• . . .Only casual attention has been given to the
  proposition that one of the best protections
  available against low birthweight and other poor
  pregnancy outcomes is to have a woman actively
  plan for pregnancy, enter pregnancy in good
  health with as few risk factors as possible, and
  be fully informed about her reproductive and
  general health.
• IOM, Preventing Low Birth Weight, 1985, p
  119.

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The 1980s, cont.
In 1989, the Expert Panel on the Content of
Prenatal Care suggested that the preconception
visit may be the single most important health
care visit when viewed in the context of its
effect on pregnancy. The Panel noted that
preconception care is likely to be most effective
when services are provided as part of general
preventive care or during primary care visit for
medical conditions. Expert Panel on
Prenatal Care. Caring for Our Future, 1989
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The 1990s

• The March of Dimes Birth Defects Foundation, in
  its publication Toward Improving the Outcome of
  Pregnancy, the 90s and Beyond emphasized the
  recommendation of its Committee on Perinatal
  Health which stated, relative to preconception
  and interconception care, the following

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• Risk reduction should be emphasized and family
  planning counseling and services routinely
  available. Preconception or interconception
  visits annually, as well as a prepregnancy
  planning visit, should become standard components
  of care.
• March of Dimes Birth Defects Foundation, TIOP,
  1993 p iv.

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The 1990s cont

• Healthy People 2000, the national health
  promotion and disease prevention objectives for
  the nation, moved preconceptional care into a
  standard expectation within the health care
  system with the following objective

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• Increase to at least 60 the proportion of
• primary care providers who provide age-
• appropriate preconception care and
• counseling.
• DHHS, Healthy People 2000, 1990 p 199.

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The 1990s, cont

• ACOG published its first technical bulletin on
  preconception care in 1995. In this bulletin,
  ACOG recommended that routine visits by women who
  may, at some time, become pregnant are important
  opportunities to emphasize the importance of
  prepregnancy health and habits and the advantages
  of planned pregnancies.
• ACOG, Technical Bulletin 205, 1995

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The Current Decade

• In 2005 the CDC determined that, . . . in light
  of the nations reproductive outcomes, the time
  had come to ensure that efforts to improve
  perinatal outcomes not be limited to prenatal
  care (best described as anticipation and
  management of complications in pregnancy) . . .

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• but be expanded to include preconception
  health and health care (described to include
  prevention and health promotion before
  pregnancy).
• Atrash, et al. MCHJ 200610S3

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The Current Decade

• In 2005, the CDC convened the Select Panel on
  Preconception Care comprised of specialists in
  obstetrics and gynecology, nursing, public
  health, midwifery, epidemiology, dentistry,
  family practice, pediatrics and other
  disciplines.
• In the same year, CDC hosted the first National
  Summit on Preconception Care.

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The Current Decade, cont.

• In April, 2006 the CDC and the Select Panel
  released Recommendations to Improve Preconception
  Health and Health CareUnited States The
  recommendations were based on
• Review of published research
• CDC/ASTDR Work group representing 22 CDC programs
• Presentations at the National Summit on
  Preconception Care, 2005
• Proceedings of the Select Panel on Preconception
  Care, 2005
• Click here to access full report.

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CDC Definition of Preconception Care

• Preconception care is a set of interventions that
  aim to identify and modify biomedical, behavioral
  and social risks to a womans health or pregnancy
  outcome through prevention and management
• It is more than a single visit and less than all
  well-woman care

CDC and Select Panel, 2006
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CDC Preconception Care Framework
Vision Improve health and pregnancy outcomes
Goals Coverage Risk Reduction Empowerment
Disparity Reduction
Recommendations Individual Responsibility -
Service Provision Access Quality Information
Quality Assurance
Action Steps Research Surveillance Clinical
interventions Financing Marketing Education
and training
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Related Vocabulary

• Preconception
• Health status and risks before first pregnancy
  health status shortly before any pregnancy
• Periconception
• Immediately before conception through
  organogenesis
• Interconception
• Period between pregnancies

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WHAT IS PRECONCEPTION CARE?

• Giving protection
• Managing conditions
• Avoiding exposures known to be teratogenic

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Giving Protection

• Examples of giving protection
• Folic acid supplementation to protect against
  neural tube defects and other congenital
  anomalies
• Protection against infectious diseases
• Rubella
• Varicella
• Hepatitis B
• HIV/AIDs

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Managing Conditions

• Examples of conditions known to be detrimental to
  reproductive outcomes if in poor control before
  conception
• Diabetes
• Maternal PKU
• Obesity
• Hypothyroidism
• Sexually transmitted infections

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Avoiding Exposures

• Examples of exposures known to be teratogenic or
  otherwise harmful in early pregnancy
• Medications
• Many antiseizure medications
• Oral anticoagulants
• Accutane
• etc
• Alcohol
• Tobacco

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Some of these topics are already covered in my
routine well woman carewhats the difference?
Comprehensive well woman care is, in fact,
preconception care for women who may become
pregnant. Some women may need more than routine
well woman care but no woman needs less.
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Examining the Link between Promoting Womens
Health and Promoting Preconceptional Wellness

• Major threats to womens health are also major
  threats to reproductive outcomes.

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NUTRITIONAL STATUS Obesity

• Impact of obesity on womens health
• Diabetes
• Hypertension
• Cardiovascular disease
• Disabilities

• Impact of maternal obesity on reproductive
  outcomes
• Glucose intolerance of pregnancy
• Pregnancy induced hypertension
• Thrombophlebitis
• Infertility
• Neural tube defects
• Prematurity

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NUTRITIONAL STATUS Underweight

• Impact of being underweight on womens health
• Risk of osteoporosis in later life
• Fragile health status

• Impact of low pregravid weight on reproductive
  outcomes
• Infertility
• Low birth weight
• Prematurity

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NUTRITIONAL STATUS Specific nutrients

• Impact of low folate levels and womens health
• Increased heart disease Evidence accumulating
  about increases in
• Colon cancer
• Breast cancer
• Some forms of dementia

• Impact of inadequate maternal folate levels on
  reproductive outcomes
• Increased incidence of neural tube defects
• Increased incidence of other birth defects
• Some anemiasmother and infant

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SUBSTANCE USE

• Impact of alcohol use on womens health
• Risk for motor vehicle and other accidents
• Risk for unintended pregnancy
• Risk for addiction
• Risk for nutritional depletions and inadequacies

• Impact of alcohol use on reproductive outcomes
• Delayed fertility
• Increased SABs
• Fetal alcohol spectrum disorders (full fetal
  alcohol syndrome can only occur with fetal
  exposure between days 17-56 of gestation)

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SUBSTANCE USE

• Impact of tobacco use on reproductive outcomes
• Leading preventable cause of infant mortality
• Preventable cause of low birth weight and
  prematurity
• Associated with placental abnormalities including
  placenta previa and placenta abruptio

• Impact of tobacco use on womens health
• Implicated in most of the leading causes of death
  for women
• Heart disease (1 cause of death)
• Stroke (2)
• Lung cancer (3)
• Lung disease (4)

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PERIODONTAL DISEASE

• Impact of periodontal disease on womens health
• Heart disease
• Stroke
• Serious threat to women with diabetes,
  respiratory diseases, osteoporosis

• Impact of periodontal disease on reproductive
  outcomes
• Evidence accumulating that may be a preventable
  cause of prematurity

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PotentialAdvantages of Regularly Addressing
these Issues with Every Woman Who Might Someday
Conceive

• Higher levels of wellness for the woman
• Higher levels of preconceptional health should a
  woman become pregnant
• Improved pregnancy outcomes
• Likely higher rates of pregnancy intendedness
  for those who become pregnant

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Some Thoughts on Changing the Reproductive
Prevention Paradigm to include the Preconception
Period
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Three Tier Approach to Achieve Higher Levels of
Well Woman/Preconception Wellness

• General Awareness (Social marketing)
• Routine Health Promotion (Every woman, Every
  time)
• Specialty care

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The Three Tier Approach to Achieve the
Preconception Agenda Click on the following
bullets for more information on each tier

• General Awareness (Social marketing)
• Routine Health Promotion (Every woman, Every
  time)
• Specialty care
• These tiers are intertwined and
  interdependentall
• three are necessary to move the agenda forward
• successfully and systematically

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Issues in General Awareness

• The concept preconceptional means nothing to
  the general public
• Few (professionals, patients, men, future
  grandmothers, etc.) understand how important the
  earliest weeks of pregnancy are
• Women most in need of preconceptional health
  promotion are often those least likely to have
  intended conceptions

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• For examples of preconceptional
• health promotion patient
• education materials
• Visit http//www.marchofdimes.com/professionals/19
  605.asp

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Issues in Routine Health Promotion
What We Dont Need. . . A new categorical service
called the Preconception visit
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Routine Health Promotion
What We Do Need. . . Reorientation of services to
Every Woman. . .Every Time
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For Every Woman of ChildbearingPotential Every
Time She is Seen

• Identify modifiable and nonmodifiable risk
  factors for poor health and poor pregnancy
  outcomes before conception
• Provide timely counseling about risks and
  strategies to reduce the potential impact of the
  risks
• Provide risk reduction strategies consistent with
  best practices.

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Every WomanEvery Time is Opportunistic Care

• Takes advantage of all health care encounters to
  stress prevention opportunities throughout the
  lifespan
• Recognizes that in almost all cases
  preconceptional wellness results in good health
  for women, irrespective of pregnancy intentions
• Addresses conception and contraception choices at
  every encounter
• Involves all medical specialtiesnot only those
  directly involved in reproductive health
• The every womanevery time theme will be the
  focus of Module 2 of this curriculum.

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Issues in Specialty Services

• Identify women with high risk conditions (e.g.
  medical conditions, history of poor pregnancy
  outcomes, etc.) and provide information on the
  nature of the risks
• Provide women with appropriate evidence based
  care (see module 3 Target Service for
  Women/Couples with High Risk Conditions) or refer
  her to a specialist or subspecialist prepared to
  offer consultation or to assume management of the
  womans condition
• Specialists and subspecialists need to consider
  lifespan issues beyond their own specialty so
  that the woman receives comprehensive assessments
• Care regimens and recommendations must be
  coordinated between referring and referral
  providers to avoid patient confusion

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How Does the Clinician Fit Preconceptional Health
Promotion into an Encounter?

• If you take care of women of reproductive
• potential . . .Its not a question of whether
• you provide preconception care, rather its a
• question of what kind of preconception care
• you are providing.
• Joseph Stanford

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Challenge you to enrich your office strategies
for health promotion/disease preventionWhat
are three changes you can make?
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How will this curriculum help me clinically? How
will it help achieve the national agenda?
The CDCs report includes 10 recommendations.
All of these recommendations will be advanced
through this curriculum
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First The Specific Goals of the CDC
Preconception Initiative are to

• Improve the knowledge, attitudes and behaviors of
  men and women related to preconceptional health
• Assure that all women of childbearing age in the
  United States receive care services that will
  enable them to enter pregnancy in optimal health

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CDCs 10 Recommendations to Improve Preconception
Health
April 21, 2006
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CDC Recommendation 1

• Each woman, man and couple should be encouraged
  to have a reproductive life plan
• Note Examples of reproductive life plans
  
• and their uses will be presented in
• Module 2 of this curriculum Every
• WomanEvery Time

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CDC Recommendation 2

• Increase public awareness of the importance of
  preconception health behaviors and preconception
  care services by using information and tools
  appropriate across various ages literacy,
  including health literacy and cultural/linguistic
  contexts
• Note Examples of educational materials and
  tools
• can be found under Practice Supports
  in the
• CE menu for this curriculum

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CDC Recommendation 3

• As a part of primary care visits, provide risk
  assessment and educational and health promotion
  counseling to all women of childbearing age to
  reduce reproductive risks and improve pregnancy
  outcomes
• Note Case studies illustrating appropriate
  content
• are highlighted in Module 2 of this
• curriculum, Every Woman, Every Time.

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CDC Recommendation 4

• Increase the proportion of women who receive
  interventions as follow-up to preconception risk
  screening, focusing on high priority
  interventions.
• Note Interventions proven effective for
  specific high risk
• conditions and circumstances will be
  featured in
• Module 3 of this curriculum,
  Maximizing Prevention.
• In addition, key articles and clinical
  practice guidelines
• have been organized by condition and
  annotated.
• These can be found under What the
  Evidence Says
• in the CE menu of this curriculum.

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CDC Recommendation 5

• Use the interconception period to provide
  additional intensive interventions to women who
  have had a previous pregnancy that ended in an
  adverse outcome (e.g. infant death, fetal loss,
  birth defects, low birth weight, preterm birth,
  significant maternal morbidity)
• Note Case studies illustrating appropriate
  areas for
• investigation and intervention will
  be
• presented in module 4 of this
  curriculum, In
• Between Time.

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CDC Recommendation 6

• Offer, as a component of maternity care, one
  prepregnancy visit for couples and persons
  planning a pregnancy
• Note Meeting this recommendation will require
  modification of
• third-party reimbursement policies.
  Watch Breaking News
• in the CE menu of this curriculum for
  updates on coding and
• payment advances. In the meantime,
  module 2 of this
• curriculum, Every Woman-Every Time
  provides guidance
• on incorporating preconceptional
  health promotion into
• routine well woman and annual exams.

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CDC Recommendation 7

• Increase public and private health insurance
  coverage for women with low incomes to improve
  access to preventive womens health and
  preconception and interconception care.
• Note Watch Breaking News in the CE menu for
• this curriculum for updates on public
  policies
• to support preconception health and
  health
• care.

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CDC Recommendation 8

• Integrate components of preconception health into
  existing local public health and related
  programs, including emphasis on interconception
  interventions for women with previous adverse
  outcomes.
• Note Links to model programs can be found under
  
• Model Programs in the CE menu for
  this
• curriculum

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CDC Recommendation 9

• Increase the evidence base and promote the use of
  the evidence to improve preconception health.
• Note Content of the modules is evidence based.
  In
• addition, key articles and clinical
  practice
• guidelines have been organized by
  condition and
• annotated. These can be found under
  What the
• Evidence Says in the CE menu of this
  curriculum.
• The curriculum is continually being
  updated to provide
• clinicians with the most current state
  of the science and
• state of the art.

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CDC Recommendation 10

• Maximize public health surveillance and related
  research mechanisms to monitor preconception
  health.
• Note Watch Breaking News in the CE menu for
• this curriculum for updates on public
  policies
• to support preconception health and
  health
• care.

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You Are Now Done with Module 1

• Now that you have finished Module 1 of the
  curriculum you have these options
• Take the post test and register for the
  appropriate CMEs
• Move on to any of the other modules we
  recommend they be taken in order but this is not
  essential
• Explore the rest of this website for the other
  offerings to help you incorporate evidence-based
  preconception care into your practice.

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Post test

• If you desire CME credit for Module 1, click here.